Cases of multicystic ovaries with primary hypothyroidism
have been reported in girls as a cause of pseudoprecocious
puberty,[1,2] and in adult females with abdominal pain.[3] The
ovarian cysts are thought to be due to increased ovarian
sensitivity to gonadotropins[4] or more likely an action
of increased circulatory levels of thyroid stimulating
hormone (TSH) (secondary to chronic untreated primary
hypothyroidism) on follicle stimulating hormone (FSH)
receptor (FSHR) causing gonadal stimulation.[5,6] Here
we report a case of juvenile primary hypothyroidism
presenting in adulthood as abdominal mass due to huge
bilateral ovarian cysts.

A 16-year-old Indian girl presented with increased facial
hair growth, weight gain, amenorrhea and generalized
weakness for the last 3 months. On examination she was
found to have severe hirsutism, her modified Ferriman-
Gallwey score was 24/36, she had broad purple striae on
abdomen, hypertension and proximal myopathy. On
investigations, the patient was found to have ACTH
dependent Cushing's syndrome.

A 72-year-old man presented with palpitation, dyspnea, and chest discomfort. Initial investigations revealed atrial fi brillation (AF)
and pericardial effusion, further investigations unraveled primary hypothyroidism (thyroid stimulating hormone) of 34.7 IU/ml and
total thyroxine (T4) of 5.57 g/dl). Treatment with levothyroxine led to resolution of symptoms, AF, and pericardial effusion.

AVASCULAR NECROSIS OF FEMORAL HEAD

Introduction

Bone is a living tissue and it needs blood supply to survive. If there is damage to one of the blood supply, bone may depend on the accessory blood supply for the survival. But certain bones in our body have precarious unidirectional blood supply like Head of femur, scaphoid, and talus.
When there is damage to blood supply to the head of femur it results in the death of cells in the femoral head. Gradually there is collapse of femoral head with loss of sphericity. This condition is referred to as Avascular necrosis of femoral head or Osteonecrosis (bone death) of femoral head.

How AVN develops in femoral head?

Hip joint is a ball and socket type of synovial joint. The socket is formed by cup shaped acetabulum which surrounds the ball (femoral head - upper end of thigh bone). The surface of femoral head and socket is lined by thick articular cartilage and then lined by synovial membrane. All together with the surrounding joint capsule and muscles form a hip joint.

The ball of hip joint receives most of its blood supply through the neck of thigh bone. If there is damage to this blood supply there is no accessory blood supply to the femoral head.
There is gradual death of cells in femoral head due to loss of blood supply. Due to death of bone cells, there is no reparative process of bone formation and resorption. Gradually the bony structure in the femoral head weakens and starts to collapse. When AVN develops in the head femur, the weight bearing area of the head is the first place to collapse. The rounded contour of the femoral head is lost and it becomes flattened causing abnormal movement in the hip joint.
Secondary osteoarthritis develops, as there is gradual wear in ball and socket of the hip joint.

Causes:
Many causes have been identified

Trauma: Fractures
Damage to the blood supply of femoral head usually occurs following a trauma or fractures to the bones in and around the hip joint.
 Fracture of Femoral neck, Femoral head
 Hip Dislocations
 Bad fractures of acetabulum
AVN can develop months or some times after initial injury.

Drugs:
Steroids:
Some steroids like cortisone, prednislone or methyprednisolone are known to cause AVN. In certain conditions like bronchial asthma, skin diseases, some auto immune disorders, inflammatory arthritis and in cases of organ transplant to prevent rejection, use of steroids is must to control or treat these conditions. Orally prescribed steroid are notorious in producing AVN of femoral head. There have been studies to show that steroid given in the form of injections into the joints or bursa does not cause any AVN of femoral head.

Blood disorders:
Some blood diseases like sickle cell disease, Leukemia’s, Gauchers disease and diseases related to blood coagulation can cause AVN of femoral head.

Lifestyle:
Studies have shown that alcohol and smoking can cause AVN in femoral head. Chronic alcohol intake can damage blood vessels leading to AVN. Smoking cause narrowing of small blood vessels and thereby reducing blood supply to the femoral head.

Others:
Deep see divers and miners are more prone develop AVN. Due to high atomospheric pressure tiny air bubbles are formed inside the blood stream which can block the tiny blood vessels in the femoral head there by resulting in AVN.

Symptoms

What does AVN feel like?
1. Pain:
Initially patient complains of pain in the affected hip which gradually increases on weight bearing. As the disease progresses patient complains of pain at rest and at night.
2. Limping
3. Stiffness
4. Difficulty in sitting cross legged and squatting
5. Shortening of affected limb

Diagnosis

How do doctors identify the condition?
1. History: doctor enquires about
- Occupation
- Medical problems and any medications like steroids
- Alcohol and smoking

2. Examination: doctor examines hip for
- Range of movements
- Stiffness

3. X-rays:
X - rays do not show any changes of AVN in the early stages of disease even though patient is having pain in the hip. It may take few months to observe changes of AVN and make diagnosis on X - ray.

4. MRI:
MRI can detect early changes of AVN in the femoral head that cannot be seen on X- ray. It helps to detect damaged areas of blood supply to the hip. AVN of femoral head can be graded as mild, moderate and severe depending on the size location of these damaged areas and if any collapse has occurred in the MRI images. MRI can also help to detect AVN changes in the opposite hip even though there are no symptoms.

5. Bone scan:
Bone scan involves injecting a radioactive chemical into the blood. Hours after injection a special camera is used to take pictures of your skeleton. The picture shows blank spot in the areas of femoral head which is devoid of blood supply. MRI has replaced Bone scan in diagnosing the cases of AVN of femoral head.

Treatment
What are the treatment options for AVN of femoral head?
AVN of femoral head is irreversible resulting in arthritic hip. Some drugs and salvage procedures can help in delaying the progress of disease. The choice of treatment depends upon the stage of the disease. Some factors like age of the patient, general health of patient and activity level also determines the treatment methods.

Nonoperative treatment:

If avascular necrosis of femoral head is diagnosed in early stages, some of following treatment methods can help in delaying the progress

1. Protected weight bearing on the affected limb with the help of crutches or walker can help reduce pain. The idea behind it is, it permits healing and prevents further damage.
2. Exercises and stretches prevent stiffness in the hip and helps to maintain range of motion.
3. Medications:
A. Bisphosphnates : This group of drugs help to reduce the risk of femoral head collapse in patients with Avascular necrosis.
B. Blood thinners: They are given in view of improving blood circulation to the femoral head.
C. Anti-inflammatory medications / simple analgesics to reduce pain.

The above mentioned treatment modalities may delay the progression of disease, but not completely reverse the Avascular necrosis.

Surgical management:

Salvage procedures: Some surgical procedures can try to decrease the pressure in femoral head and increase the blood supply. The main prerequisite for such surgeries is that there should not be any collapse in the femoral head. Many procedures have been designed to improve the blood supply of femoral head. Your surgeon can choose and suggest appropriate procedure.

Core decompression of femoral head:

The most common surgical procedure is to drill one or several holes into the femoral neck and head trying to enter into areas of poor blood supply. The idea behind this procedure is one that it creates a new path for new blood vessels to grow into areas of poor blood supply and it relieves pressure inside the femoral head. The other advantage of this procedure is that there is pain relief secondary to relieving pressure in the femoral head.
Core decompression of femoral head can be supplemented with bone grafting with or without stem cells injection

Core Decompression and Bone grafting of femoral head:

Following core decompression procedure bone graft is packed into the dead part of femoral head and channel created in the femoral head and neck. The bone graft can be taken from the patient or from the bone bank. The bone graft is made into tiny pieces and packed into the channel created in the femoral head and neck.

Stem cells treatment:

Stem cells obtained from the patient body can be injected into the channel created for core decompression of femoral head. Stem cells injection can be done along with bone grafting also. There are studies showing that stem cells help to stimulate new bone formation in the diseased areas of the femoral head.

Postoperative rehabilitation after core decompression surgery:
This surgical procedure is done through a very small incision from the side of thigh. Surgeon guides the drill into the femoral head with help of intraoperative X - ray machine (C-Arm). This procedure is usually done as outpatient procedure and patient can go back to the house on the same day with help of crutches or walker.

Following core decompression surgery the drill holes in the femoral neck and head may weaken the bone, making it susceptible to fracture. So patients are advised to use crutches or walker to move around for six weeks. After six weeks, patient patients are advised to put full weight on operated leg and take advice of physiotherapist to regain hip range of motion and strength.

Advantages of core decompression surgery:
Core decompression of femoral head is NOT A DEFINITIVE procedure. It is a salvage procedure to delay the process of Avascular necrosis probably by increasing blood supply and also preventing further collapse.
After the core decompression procedure it is necessary to continue, the medications explained above as they also help in delaying the progress of disease.

Core decompression and Vascularized fibular grafting:

In the first step surgeons drills a hole into the femoral neck and head. In the next step surgeon removes small part of fibula (Thin bone by the side of shin bone in leg) along with its blood vessels. This is referred as vascularized fibular graft because it has its own blood supply. Fibular graft is inserted into the channel created in the neck and head of the femur. Vascular surgeon attaches the blood vessels from the fibula to one of the blood vessels in the hip. This procedure does two things
1. Fibular graft acts as structural support preventing collapse of femoral head.
2. The newly connected blood vessels try to increase blood supply to the femoral head.
This is a very complicated procedure and needs special expertise. The success of the surgery depends on the viability of newly created blood supply. It is rarely practiced nowadays.

TOTAL HIP REPLACEMENT:

The process of Avascular necrosis of femoral head invariably ends in arthritic hip. In arthritic hip, joint surfaces of femoral head and acetabulum becomes irregular with loss of motion in the joint. The treatment choice is total hip replacement.

Total hip replacement is procedure in which the surgeon replaces the damaged femoral head and damaged joint surface of acetabulum (socket) with prosthetic components. Damaged femoral head is removed and replaced with metallic stem and ball. Damaged cartilage of the socket of hip joint is replaced with metal socket.

Prosthetic components:
Total Hip replacement can be either cemented or uncemented.

Cemented Total hip replacement: In this procedure, cement is used for fixation of the prosthetic components into the bone.
Uncemented Total Hip replacement: In this technique, the fixation of components is by “pressfit” into the bone which allows bone to grow onto the components.

Prosthetic materials:
Total hip replacement has wide range of designs and materials.
The stem component and socket components in the total hip arthroplasty are invariably medical grade steel or titanium alloys. There is choice of material selection for the prosthetic head and liner of socket. Prosthetic heads can be metallic or ceramic. Socket liners are available in plastic, metallic and ceramic materials.
Different combinations of metal heads and liners can be made depending on needs of the patient.
Metal on plastic (Metal head / Plastic liner)
Ceramic on plastic (Ceramic head / Plastic liner)
Metal on metal (Metal head / Metal liner)
Metal on ceramic (Metal head / ceramic liner)
Ceramic on ceramic (Ceramic head / Ceramic liner)

The decision to use cemented or uncemented components and various combination of head and socket liners are based on various factors such as age, bone quality and sometimes surgeons choice.

RESURFACING ARTHROPLASTY:
In certain patients with limited damage to the part of femoral head surgeon may consider resurfacing arthroplasty. In this procedure surgeon replaces only damaged femoral head with metallic implant.

EFFECTIVENESS OF FALDENKRAIS THERAPY WITH ROLF’S MOBILIZATION ON PAIN AND DISABILITY IN CHRONIC LOW BACK PAIN- A COMPARATIVE STUDY”
INTRODUCTION
Low back pain (LBP) is defined as pain localised between the 12th rib and the inferior gluteal folds, with or without leg pain. LBP has a lifetime prevalence of 60–85%. At any one time, about 15% of adults have LBP. LBP poses an economic burden to society, mainly in terms of the large number of work days lost (indirect costs) and less so by direct treatment costs. A substantial proportion of individuals with chronic LBP has been found to have chronic widespread pain. LBP is often associated with other pain manifestations such as headache, abdominal pain and pain in different locations of the extremities. Widespread pain is associated with a worse prognosis compared to localized LBP.2
Chronic low back pain may originate from an injury, disease or stresses on different structures of the body. The type of pain may vary greatly and may be felt as bone pain, nerve pain or muscle pain. The sensation of pain may also vary. For instance, pain may be aching, burning, stabbing or tingling, sharp or dull, and well-defined or vague. The intensity may range from mild to severe. Many times, the source of the pain is not known or cannot be clearly defined. In fact, in many instances, the condition or injury that triggered the pain may be completely healed and undetectable, but the pain may still continue to bother you. Even if the original cause of the pain is healed or unclear, the pain you feel is real. It is your health care provider’s job respect your experience of pain, regardless of its cause.1

There are enormous causes of low back pain. This constitutes congenital, traumatic, inflammatory, degenerative, neoplastic, metabolic, postural, idiopathic, pain referred from viscera, genitourinary diseases, pregnancy, gynaecological diseases etc.3

Low back pain (LBP) is the main cause of absenteeism and disability in industrialized societies. Approximately 10%-20% of patients with LBP develop chronic LBP,defined as pain and disability. 4
Chronic low back pain is a common symptom that presents as localised or widespread pain in the lower back, often accompanied by a lack of flexibility and tenderness in the lower back. This condition is defined by activity intolerance due to lower back or leg symptoms (sciatica) lasting more than three months.5

Chronic low back pain may originate from an injury, disease or stresses on different structures of the body. The type of pain may vary greatly and may be felt as bone pain, nerve pain or muscle pain. The sensation of pain may also vary. For instance, pain may be achey, burning, stabbing or tingling, sharp or dull, and well-defined or vague. The intensity may range from mild to severe. Chronic low back pain may be the result by many different conditions. It may start from diseases, injuries or stresses to a number of different anatomic structures including bones, muscles, ligaments, joints, nerves or the spinal cord. The affected structure sends a signal through nerve endings, up the spinal cord and into the brain where it registers as pain.6
Psychological factors are even more important in people with chronic back pain. Dissatisfaction with a work situation, a supervisor, or a dead-end job and boredom contribute greatly to the onset and persistence of back pain7


Low back pain can be caused by a variety of conditions including musculoskeletal, osteoarticular and neurogenic disorders. Over the past 30 yrs, the rate of disability claims related to low lackache has increased by 14 times the rate of population growth.9

Low back pain (LBP) is a very common but largely self-limiting condition. The problem arises however, when LBP disorders do not resolve beyond normal expected tissue healing time and become chronic. Eighty five percent of chronic low backpain (CLBP) disorders have no known diagnosis leading to a classification of ‘non-specific CLBP’ that leaves a diagnostic and management vacuum. Even when a specific radiological diagnosis is reached the underlying pain mechanism cannot always be assumed. It is now widely accepted that CLBP disorders are multi-factorial in nature. However the presence and dominance of the patho-anatomical, physical, neuro-physiological, psychological and social factors that can influence the disorder is different for each individual. Classification of CLBP pain disorders into sub-groups, based on the mechanism underlying the disorder, is considered critical to ensure appropriate management.10

Despite considerable efforts to solve the problem of chronic low back pain (CLBP), it still has a high prevalence and considerable socioeconomic consequences all over the industrialized world. It would be advantageous to identify at an early stage those patients at high risk of developing persistent or recurrent low back pain (LBP) and to direct the treatment (active or multidisciplinary) modalities to that group.11

Muscular dysfunction plays an important role in the pathogenesis of low back pain syndromes, and forms an essential part in postural defects . In response to mechanical derangement and pain certain muscle groups, the postural muscles, show a tendency to get hypertonic and tight, and are readily activated in most movement patterns . They are less liable to atrophy and have a pronounced postural function . They include the hamstrings, iliopsoas and trunk extensors. The opposite group, the phasic muscles, on the contrary, tend to react to a given situation by inhibition, atrophy and weakness . They include the abdominals, and the glutei.12

Back pain is among the commonest rheumatological complaints and is responsible for a substantial proportion of total morbidity and loss of work through illness.13

More than 85% of patients who present to primary care have low back pain that cannot reliably be attributed to a specific disease or spinal abnormality (nonspecific low back pain).14

About 60% to 80% of the population in the western world will experience low back pain (LBP) at some stage in life. Due to a favorable prognosis in the acute stages, 80% to 90% of the patients will improve considerably within 6 to 8 weeks.10,26,46 The prognosis for chronic LBP is considerably less favorable, causing potentially long-lasting suffering to the patient and significant socioeconomic costs.15

Treatment targets are reduction of pain and better activity/participation, including prevention of disability as well as maintainance of work capacity. The evidence from selected and appraised guidelines, systematic reviews and major clinical studies was classified into four levels, level Ia being the best level with evidence from meta-analysis of randomised controlled trials.2
The Feldenkrais Method was developed by Moshe Feldenkrais (1904-1984) (Reese 1985/86) after more than 40 years of refinement (Brice 1990). It is purely an educational approach, which claims neither to diagnose, treat nor cure (Rywerant 1983, p. 162). Feldenkrais believed that the cause of repeated injury, many pains and movement restrictions was predominantly the result of poor habitual use of oneself (Auburn 1985, Wanning 1993), brought about from half-learnt or badly learnt movement patterns.16

The Feldenkrais Method (FM) is an educational approach that focuses on expanding kinesthetic awareness as a basis for improving function (Stephens, 2000). FM has two different modes of instruction: Functional Integration (FI) and Awareness Through Movement (ATM). FI is individualized instruction where the individual receives hands on guidance through gentle touch. ATM consists of group lessons, verbally guided, where movements are self-directed and executed within each individual’s comfort range. ATM is the focus of this investigation.17

The Feldenkrais Method is a way of learning — learning to move more freely and easily, to carry less stress in your body, to stop doing the things that cause you pain. Through gentle movement and directed attention, it enhances your self-awareness to put you back in touch with yourself, with the fluid, easy movement that is your birthright. We call this kind of learning somatic education.18

The Feldenkrais Method is an approach to improve peoples' ability to learn and to function through simulating the exploratory style of learning natural to infants. people can learn new patterns of movement specifically designed to expand body awareness and to enhance the neuromuscular self-image through more efficient and comfortable movement.19

ATM lessons are 10 to 60 minutes in length and movements are performed slowly and gently. Pain and effort during the lesson (straining and compensatory motions) are avoided, as the occurrence of pain would trigger a defensive muscle pattern, which would interfere with improvement. ATM begins with simple, minute movements, which are used to reduce latent tonus (degree of involuntary muscle contractions) and to learn how to direct and maintain attention. As the individual progresses, the movements become more advanced in their complexity, speed, size, and trajectory of motion until the movements are functional and can be applied to daily activities (Houglum, 2005). 17,18

Some studies have suggested that ATM produces a change in the amount of muscular activity as measured by electromyography (EMG). Perceptual recognition of the change in muscular activity is produced and this recognition is not the direct result of the use of suggestion, imagery, and visualization.17

Stephens et al. (2001) investigated the effects of the ATM on balance and balance confidence in people with multiple sclerosis and found significantly improved balance confidence compared to controls.20

Lundblad, Elert, and Gerdle (1999), in a randomized controlled trial of 97 subjects, found significantdecrease in neck and shoulder pain and disability for participants in the Feldenkrais group (that included both modes ATM and FI) compared to the control and physiotherapy groups.21

Research by Bearman and Shafarman (1999), showed significant increases in functional mobility in seven participants, both immediately after an eight-week program of ATM lessons and in a one-year follow-up questionnaire. These studies demonstrate the benefits of the Feldenkrais Method on pain perception, mobility and improving body mechanics in participants with RA and neck and shoulder pain.22

Smith and colleagues (2001) assessed pain in three dimensions, affective, sensory and evaluative on 26 subjects. After a 30-minute ATM lesson, significant differences in pain reduction were found between the ATM and control groups in the affective dimension of pain. No significant differences were found in the sensory and evaluative dimensions.23

Rolfing Structural Integration is a form of bodywork that aims to align the body in the gravitational field by manual manipulation of the body’s neuro-myofascial system. Rolfing was developed by Ida P. Rolf, PhD, a biochemist who developed the 10-series of Structural Integration over 50 years ago. The series aims to get the major segments of the body aligned and coordinated so ease and comfort can be experienced in a client’s body. Rolfing can create a more effective use of muscles, thereby conserving energy during movement due to more refined, economical patterns.24

If you can imagine how it feels to live a fluid, light, balanced body, free of pain, stiffness and chronic stress, at ease with itself and the gravitational field, then you will understand the purpose of Rolfing.
Rolfing achieves its remarkable results by manipulating the myofascial system. The myofascial system is composed of muscle tissue and a form of connective tissue called fascia. it is not a form of massage, bodywork, deep tissue, myofascial or osseous release therapy. Rather, Rolfing is a form of holistic/integrative somatic education and manipulation that deals not just with the symptoms of distress, but with the whole person in relation to gravity.25








Figure 1.1: Rolf’s mobilization

Rolfing is well known for getting quick and long lasting results with a wide variety of problems, as well as dramatically changing posture and enhancing one's performance in many activities.
Here are a few examples of what Rolfing has been known help:
• Postural Correction
• Back Pain
• Neck Pain and Headaches
• TMJ
• Sports Injuries
• Auto Injuries
• Carpel Tunnel Syndrome
• Greater Flexibility and Freedom of Movement
• Increased Well-Being
• Performance Enhancement

Rolf (47) and Gordon (19) have proposed the use of soft tissue mobilization and guided movement techniques for treating low back pain conditions that have been correlated with pelvic asymmetry in the sagittal plane. They assume that sacroiliac joint dysfunction, including unilateral and bilateral rotations of the innominate bones, is a major contributing factor to biomechanically induced low back pain.26

The sacroiliac joints are often considered a source of low back pain 1-7 Debate has continued over the existence of sacroiliac joint dysfunction. Some view the sacroiliac joint as an insignificant contribution to low back pain & l0 whereas others believe the sacroiliac joint plays a major role in low back pain.27
A case study indicates that a holistic approach using Rolfing and movement education shows greater promise in treating low back pain than the corrective approach.25
Cottingham and Kent Richmond shows The effects of soft tissue manipulation (Rolfing method) were evaluated on young healthy men using two dependent variables: 1) angle of pelvic inclination and 2) parasympathetic activity. The results provide theoretical support for the reported clinical uses of soft tissue pelvic manipulation for 1) certain types of low back dysfunction and 2) musculoskeletal disorders associated with autonomic stress.28

Hence, this study was designed to determine the effectiveness of two forms of therapy interventions such as Feldenkrais therapy and Rolf’s mobilization in participants with chronic Low Back Pain on visual analogue scale and Modified oswestry Low Back Pain disability questionnaire.







AIMS AND OBJECTIVES OF STUDY
1. To study the effectiveness of feldenkrais therapy along with back exercises in chronic low back pain.
2. To study the effectiveness of rolf’s mobilization along with back exercises in chronic low back pain.
3. To compare the effectiveness between feldenkrais therapy and rolf’s mobilization along with back exercises in chronic low back pain.
HYPOTHESIS
(1) Null Hypothesis (H0):
There is no significant effect on pain and disability in subjects treated with feldenkrais therapy and rolf’s mobilization in low back pain.
(2) Experimental Hypothesis (H1):
There is significant effect on pain and disability in subjects treated with feldenkrais therapy and rolf’s mobilization in low back pain.
STATEMENT OF THE QUESTION

In patients with chronic low back pain,will feldenkrais therapy along with back exercises compared to of rolf’s mobilization along with back exercises,bring about reduction in VAS score for pain relief and reduction in MOLBPD questionnaire for improvement in functional ability?


OPERATIONAL DEFINITIONS
Pain: “An unpleasant sensation, occurring in varying degrees of severity as a consequence of injury, disease, or emotional disorder.”29
Chronic pain: Pain persisting beyond 7-12 weeks or beyond the usual course of an acute disease or reasonable time for an injury to heal, or it recurs at intervals for months or years.17
Low back pain: is defined as pain localised between the 12th rib and the inferior gluteal folds, with or without leg pain.2
Feldenkrais therapy: Named after its originator, Dr. Moshe Feldenkrais, twentieth century physicist, judo expert, mechanical engineer and educator. The Feldenkrais Method is a form of Somatic Education that uses gentle movement and directed attention to improve movement and enhance human functioning. 17
Awareness Through Movement: Group classes where the therapist teacher verbally leads the student through a sequence of movements in basic positions: sitting or lying on the floor, standing or sitting in a chair.16
Rolf’s mobilization: Rolfing is a series of manual manipulations of the soft tissue, or neuro-myofascial system of the body focused on improving the alignment and the level of freedom or spaciousness in the body.24
Visual analouge scale: A horizontal/Vertical visual analogue scale is used for pain assesment.A 10 cm line was drawn on a paper and participants were asked to mark a point on the line that best defined the present pain level,where 0 indicated no pain and 10 indicated severe pain.29
Modified Oswestry Low back pain disability questionnaire: It includes 10 items with score ranging from 0-50; where better function is indicated by lower scores.30

Organization of the Remaining Chapters
The remaining chapter of this thesis are as follows. Chapter 2 deals with a review of literature. Chapter 3 describes the methodology used in the stydy, including a study design,description of subjects,equipment used and method of data collection,chapter 4 deals with observation and data analysis. The result of the study discussed in chapter 5,Chapter 6 contains a discussion of the result. Chapter 7 contains the conclusion of the study, Chapter 8 contains the summary of the study. References are given in chapter 9 and in the end are the annexure containing consent form, assessment form, data collection form, master chart, Modified Oswestry Low back pain disability questionnaire and data analysis sample, Chapter 10.
 
REVIEW OF LITERATURE
Definition:
Low back pain is pain affecting the lower part of the back and can be described as acute, sub acute, or chronic.31
Chronic LBP defined as pain and disability persisting for more than 3 months.4 Low backpain (LBP) is a very common but largely self-limiting condition. The problem arises however, when LBP disorders do not resolve beyond normal expected tissue healing time and become chronic.10
Low back pain (LBP) is generally defined as a pain that occurs in an area with boundaries between the lowest rib and the creases of the buttocks.32
‘low back pain’ refers to ‘non-specific low back pain’, which is defined as low
back pain that does not have a specified physical cause, such as nerve root compression (the radicular syndrome), trauma, infection or the presence of a tumor. This is the case in about 90% of all low back pain patients.33
Low back pain (LBP) refers not to a diagnosis but to a clinical entity characterized by pain in the lumbar region which sometimes radiates to the lower extremities.34
Low back pain is considered to be chronic if it has been present for longer than three months.1






Figure 2.1: Anatomy




Epidemiology:
70–85% of all people have back pain at some time in life. The annual prevalence of back pain ranges from 15% to 45%, with point prevalences averaging 30%.35
Musculoskeletal impairment was the most prevalent impairment in people aged up to 65 years, and backand spine impairments the most frequently reported subcategory of musculoskeletal impairment (51•7%). The annual rates varied significantly by sex and age.35
Back pain of at least moderate intensity and duration has an annual incidence in the adult population of 10–15%, and a point prevalence of 15–30%. The prevalence rises with increasing age up to 65 years, after which age it drops off for unknown reasons.35
Low back pain is a complaint that many people have during some point in their lives. Overall chronic back pain affects over 25% of the bill population at any given time.31
Low back pain is a common medical problem but has decreased in frequency in the occupational setting over the past decade. The weather affects low back pain but to a minor degree. Physical factors, as well as job satisfaction, play a role in the development and perpetuation of low back pain.36
Murphy and Volinn reported good news regarding a decline in the frequency of occupational low back pain reported over a 9-year period. Data from a workers' compensation provider, Liberty Mutual Insurance Company (1987–1995), the Washington State Department of Labor and Industry (1991–1995), and the Bureau of Labor Statistics (1992–1995) were reviewed for frequency of low back claims from industrial settings. The US estimates of annual low back pain claims decreased by 34% between 1987 and 1995. More important, annual costs decreased during this time period by 58%. However, because the rate of filing remained 1.8 per 100 workers, the estimated cost of low back pain claims for 1995 was US$8.8 billion.37
In an attempt to determine the proportion of costs for components of back care, Williams et al. reported data derived from the National Council on Compensation Insurance on health care use and indemnity costs within the natural history of work-related low back pain disability. Health care costs were disproportionately distributed along the disability curve, with 20% of claimants with back pain for 4 months or more accounting for 60% ofhealth care costs. The most costly services were diagnostic procedures (25%), surgery (21%), and physical therapy (20%). Physician evaluation was 15% of the total, whereas medication costs were 2%.38

Etiology:
Chronic low back pain may originate from an injury, disease or stresses on different structures of the body. The type of pain may vary greatly and may be felt as bone pain, nerve pain or muscle pain. The sensation of pain may also vary. For instance, pain may be aching, burning, stabbing or tingling, sharp or dull, and well-defined or vague. The intensity may range from mild to severe.1
The low back or lumbar spine is made up of five bones with this in between the bones. These discs function as shock absorbers and allow for motion within the spine. Behind these discs is yhe spinal canal for the spinal nerves to run through and exit at each level of the spine. Typically the lumbar region or lower area of the back is where pain is felt due to the increase pressure that the low back supports.31
The main symptoms to low back pain are some sort of sudden ache or pain that comes after an obvious strain or injury. The pain may be felt in other areas than the low back such as the buttock and both legs. The pain can go down to the foot and depending on the area which has been injured can’t seem to mess other areas. The pain often is worse with spending and prolong sitting. Many people also reports stiffness with getting up in the morning from their bed. Another complaint is also increased pain and stabbing with sneezing and coughing due to the spasms they can go on in the back.31
Genetic factors play a greater role than environmental factors in the perpetuation of low back pain. Obesity may a be a minor factor in the causation of back pain, but is associated with chronicity. Obesity may be associated with sedentary life-style, low occupational status, and psychological distress, as well as physical strain in spinal structures that facilitate the chronicity of back pain.36
The effect of weather on musculoskeletal conditions is one of the most frequently asked patient questions. McGorry et al. attempted to answer the question in regard to the relation between weather and back pain.39
Hunter et al. also evaluated the long-term outcomes of 178 railroad employees who completed a multidisciplinary rehabilitation program. Improved function and reduced pain after rehabilitation were not predictive of return to work.40
Thomas et al. performed a prospective 12-month study on 180 patients who developed low back pain and consulted a physician. The studies reported in this article
Seem to agree that a variety of factors, both genetic and environmental, play a role in the perpetuation of pain.41

Classification:
There are many structures in the lower back that can cause severe pain. These include muscles, ligaments, tendons, bones, joints and discs. The outer rim of the disc can be a source of significant back pain due to its rich nerve supply and tendency towards injury.
Back pain can be divided into three large classifications –
 Axial pain
 Referred pain
 Radicular pain.

The treatment options here are similar to those used in treating axial pain. Diagnostic and therapeutic measures are aimed at correcting abnormalities in the muscles, ligaments and small joints of the spine.
The most common type of back pain is known as referred pain. Here, patients complain of having an achy, dull type of pain that seems to move around. The discomfort comes and goes and varies in intensity. This achy pain starts in the low back area and commonly spreads into the groin, buttocks and upper thighs.
The last type of back pain is known as radicular pain. In this case, the pain is described as deep and usually constant. It follows the nerve down the leg and is often accompanied by numbness or tingling and muscle weakness.42
Low back pain is pain affecting the lower part of the back and can be described as acute, sub acute, or chronic. Per the national institutes of health, 1785% of all people who have back pain at some time in their life (OHSU 2006). This can be seen as acute back pain lasting less than six weeks, sub acute back pain lasting six to twelve weeks or chronic back pain which last more than twelve weeks.31
CLINICAL DISORDERS:
Kauppila et al. reviewed a cohort of 400 women and 217 men who were followed with lateral lumbar radiographs over a 25-year period: 25% of women and 12% of men had degenerative spondylolisthesis of 3 mm or more. At the time of the 2nd radiograph, 32% of individuals with slippage had pain, aching, and stiffness on most days, compared with 19% of controls. After adjustment for endplate sclerosis, which was also associated with pain, slippage still had association with daily back symptoms. However, subjects with slippage did not report more disability than controls. Although degenerative displacement is common and is associated with increased prevalence of daily back symptoms, two-thirds of subjects with this problem do not report ongoing back pain.43
Cheng et al. report on prognostic factors and treatment for 23 individuals with lumbosacral chordoma. Of the 23 subjects, 14 men and 9 women, the mean age was 55 years. The mean duration of preoperative symptoms was 22 months. The mean tumor size at diagnosis was 8.1 cm. Chordomas occurred in the lumbar spine in six patients. High involvement of the sacrum was always associated with lower sacral involvement, most at S3 or lower. The 5-year and 10-year survival rates were 86% and 49%, respectively. Individuals with lumbar spine involvement had a poorer prognosis compared with those with lower sacral disease. Wide surgical excision and early radiotherapy was associated with improved outcome. Bladder and rectal function can be preserved if both S3 nerve roots are spared.44

SYMPTOMS OF LOW BACK PAIN:
Symptoms coated by Irene Bookman BSN,31
 The main Symptoms to low back pain are some sort of sudden ache or pain that comes after an obvious strain or injury.
 The pain maybe felt in other areas than the low back such as the buttock and both legs.
 The pain can go down to the foot and depending on the area which has been injured can’t seem to mess other areas.
 The pain often is worse with spending and prolong sitting. Many people also reports stiffness with getting up in the morning from their bed.
 Another complaint is also increased pain and stabbing with sneezing and coughing due to the spasms they can go on in the back.


CAUSES OF LOW BACK PAIN:
Unfortunately even with the technological advances that we have today the cause of low back pain is often very confusing. In most cases,back pain may be a symptom of from any different causes:
• Overuse
• Strenuous
• Obesity
• Injury
• Infection
• Poor muscle tone in the back
• Muscle tension or spasm
• Strain or sprain
• Ligament or muscle tears
• Joint problems
• Smoking
• Herniated desks
• Disease
• Degeneration

This typically can be seen due to decreasing own strained muscle elasticity and tone which occurs as people age. Discs also tend to lose their flexibility due to loss of fluid which decreases their ability to cushion the spine.31

INVESTIGATION:

General:
 A good patient history and a thorough physical examination by a well-trained clinician are the most important aspects of the evaluation.1
 The physician will evaluate for nerve problems by casting your strains your strains sensation and reflexes.31
 The physician also roll out for blood circulation as a potential problem for back pain and see what exactly makes the pain worse and what helps relieve the pain.31
 Physical measurements and questionnaires as diagnostic tools can be asses in Low back pain.34

Radiography
The main purpose of x ray is to look for an explanation of the pain however the findings can be nonspecific such as narrowing, sparring, or decrease in lumbar lordosis. Unfortunately on x-rays, the disks are not seen; however, the radiologist can look at the space between the vertebrae.31

Figure 2.2 : A plain radiography of spine
Magnetic resonance imaging
A MRI can be done to see the discs and other bony structures. This is a diagnostic procedure which uses a combination of large magnets, radio frequencies, and a computer to produce detailed images of organs and structures within the body.31


Figure 2.3 : Magnetic resonance imaging
Malko et al. through the use of magnetic resonance imaging, was able to measure disc volume during load cycles of five healthy volunteers, aged 27 to 52, without low back pain.45
Blood test
A full blood count and erythrocyte sedimentation rate are recommended in patients with bilateral disease or atypical clinical pictures.
Electromyography (EMG) studies
EMG or Electro diagnostic procedures can be done to assess the nerve. This can allow the doctor to see if the nerve is injured or pinched for the strain or injury which occurred. Typically this test uses small needles to pass a low level current through nerves for testing.31
Bone scan
Bone scan can be done to diagnose an infection in the low back along with fractures or other disorders of the bone. Typically a small amount of radioactive material is injected into the blood stream and will collect in the bones, particularly in areas with some abnormality.31
Computer tomography (CT) scan
CT scan can also be done since they are more detailed than general x-rays and can give a 3 dimensional view of the back.31
Diagnostic injections
Disco gram’s are done prior to surgery. This injects fluid into the disc’s to see which one is generating pain. This is then used to determine the level and type of surgery which must occur.31
Pressure transducer
Wilke et al. placed a pressure transducer in the nucleus pulposus of an asymptomatic 45-year-old man.46
Anesthetize of the zygapophysial joint
Kaplan et al. demonstrated the response of mechanical zygapophysial joint to lumbar medial branch nerve block.47

Main Outcome measures
For this purpose, pain intensity can be measured by means of Visual Analogue Scale (VAS). A 10- centimeter line marked with numbers 0 to 10 can be used where 0 symbolizes no pain and 10 is maximum pain. Subject is asked to mark his/her pain on this line as per the severity.48
A study done by Wewers & Lowe (1990), provide an informative discussion of the benefits & shortcomings of different styles of VAS.69 Price et al demonstrated the validity and reliability of the VAS to measure pain.49
A study done by boonstra et al. (2008), To determine the reliability and concurrent validity of a visual analogue scale (VAS) for disability as a single-item instrument measuring disability in chronic pain patients.50
To know how back pain has affected patients ability to manage in everyday life. The Modified Oswestry Low Back Pain Disability Questionnaire has been designed to give patient information to therapist as to how patient back pain has affected their ability to manage in everyday life.
The MOLBPDQ was designed to measure the impact of back pathology on function in terms of pain, disability and activity restriction in a low back pain population. During its validation Megan Davidson evaluate the methods currently available to measure the functional outcomes of physiotherapy treatment for low back problems. According to Davidson M: MOLBPDQ was one of the most reliable scales and had sufficient width scale to reliably detect improvement or worsening in most subjects with low back pain.51
In this questionnaire ask patient to answer every question by placing a mark in the one box that best describes their condition that day. Now, simply add up patient points for each section and plug it in to the following formula in order to calculate their level of disability: point total / 50 X 100 = % disability (aka: 'point total' divided by '50' multiply by ' 100 = percent disability) 52
ODI Scoring:
• 0% -20% : Minimal disability
• 21%-40% : Moderate disability
• 41%-60% : Severe disability
• 61%-80% : Crippled
• 81%-100% : Bed bound or exaggerating their symptoms.

Treatment:
The most favorable treatment for low back pain which is chronic in nature tends to be comprehensive. This should include focusing on functional the restoration, psycho-social factors, patient education, and pain management.31
Exercises are done to increase strength in both abdominal and spinal muscles. Other conservative treatment can include spinal manipulation, acupuncture biofeedback, traction, ultrasound, and transcutaneous electrical nerve stimulation (TENS) or steroid injections.31
There are several different general categories of treatment that are usually recommended for chronic back pain. These categories include physical therapy, medications, coping skills, procedures and alternative medicine treatments. The treating physician will tailor a program involving a combination of these options to address the patient’s needs. Involvement of a physician with special training in chronic pain management may be advisable in some cases. 6
Physical therapy includes patient education, and patient training in a variety of stretching and strengthening exercises, manual therapies and modalities (ice, heat, transcutaneous electrical nerve stimulation [TENS], ultrasound, etc.). Active therapies which the patient can continue on his or her own (such as exercise and strengthening) usually have the most permanent and long lasting effects. A home exercise program (HEP) is usually in place before the patient is discharged from therapy. Exercise and strengthening are designed to increase stability and strength around the structures in the back that are being stressed. These techniques also work to avoid deconditioning those results from decreased activity. Exercises are tailored specifically to the patient and the type of back pain being addressed. The goal of educating the patient is to prevent progressive loss of activity because of fear of movement. 6
Treatments for chronic back pain can vary greatly depending on the type and source of the pain. If a treatable source of the pain is found, then the underlying process should be treated. When the underlying cause is either not known or not treatable, then the symptoms are treated. The goals of the treatment are to reduce pain, improve quality of life and increase function.1
Treatment for chronic pain includes several different general categories. These categories include physical therapy, medications, coping skills, procedures and complementary medicine treatments. Medications used for treatment of pain are multiple and varied. They fall into several different categories. Both non-narcotic and, rarely, narcotic pain medications may be used in the treatment of chronic back pain.
Nonsteroidal antiinflammatory drugs (NSAIDs) are helpful with pain control and may help reduce inflammation. Muscle relaxants can also help with chronic pain and may enhance the effects of other pain medications. Nerve stabilizing drugs (antidepressants and antiseizure medications) are used to treat nerve-mediated pain. Coping skills are extremely important in the management of chronic back pain. Complementary medicine also provides a variety of treatments often helpful in the treatment of chronic pain. These treatments include acupuncture, dry needling, nutrition, magnets and many others.1
A new form of nonpharmacologic pain therapy for low back pain was reported by Ghoname et al.53
Jamison et al. reported on a pharmaceutical-sponsored study of 36 patients with back pain.54
Spinal manipulation involves a range of manual (hands-on) manoeuvres that stretch, mobilize or manipulate the spine, surrounding tissues and other joints in order to relieve spinal pain and improve mobility4. Treatment sometimes involves a high velocity thrust, a technique in which the joints are adjusted rapidly.5

Osteopathy
Osteopathy is an established system of diagnosis and treatment that places its main emphasis on the structural and functional integrity of the body.5, 73

Feldenkrais therapy
This technique postulate that habitual movements lead to movement problems. Pain or overall patterns of dysfunction. Through changing these patterns, the entire system or body functions better. The Alexander technique and Feldenkrais method suggest that the process by which these patterns are changed is a learning process. Feldenkrais often said his goal was to produce “flexible minds, not just flexible bodies.” This technique usually is taught in pasitions that eliminate gravity, such as lying down.21
Feldenkrais coined the terms awareness through movement and functional integration to define the teaching techniques of his method. One key difference between functional integration and awareness through movement consists primarily of verbal cues. Whereas functional integration mainly incorporates touch to facilitate movement and awareness. 56, 57,58
An example of an ATM lesson is one of the classical demonstrations of the Feldenkrais method. Moving the hand, eyes and chest in opposition without straining and streching muscles enables a person to increase their ability to rotate their trunk with less resistance describe by T.S.K.lyttle.16
It is a method of learning, rather than a form of bodywork, yet it often uses hands-on contact to communicate to the client. Other forms of bodywork such as transverse friction massage limit their purpose to the purely mechanical changes made in their target body tissues.59
In the body, the quality of movement of the bones and joints determines the efficiency of action. Our skeletal awareness either improves or degrades over the years.
With improved discernment, our actions may reach higher degrees of competency. Conversely, a blunted consciousness may lead us astray. We may harden into habitual
Postures; postures which may stiffen or pain us.60
The physics of Feldenkrais explores the concept of unstable equilibrium as a form of dynamic repose. This presumes that movement best complies with the Principle of Least Effort when the initial posture incorporates maximal potential energy with minimal inertia.61
Eva-britt malmgren-olsson indicated the group treatments using Body awareness therapy and Feldenkrais might be more effective than conventional treatment.62
A study done by Gretchen A. et al, on the ability of the Feldenkraiss Method to reduce state anxiety was investigated. Specifically, both a single Feldenkraiss Awareness through Movement lesson and a 10-week Feldenkrais.63
The effects of a Feldenkrais Awareness through Movement program and relaxation procedures were assessed on a volunteer sample of 54 undergraduate physiotherapy students over a 2-week period and found reducing anxiety.64
A study done by C. Hopper et al, on the effect of Feldenkrais awareness through movement on hamstring length, flexibility, and perceived exertion.65
A study done by Suzanne Ruth et al, showed Facilitating cervical flexion using a Feldenkrais method.66
A study done by Jeffrey C. Ives et al, on comments on “The Feldenkrais method, a dynamic approach to changing motor behavior.”67
A study done by Julie R. Dean et al, showed that the Feldenkrais Method has potential value as a possible adjunct to the physical therapy treatment of selected fibromyalgia patients.68,69
A study done by Glenna Batson et al, showed that gains in functional mobility are possible for individuals with chronic stroke using Feldenkrais movement therapy in a group setting.70
A study done by Iiana et al, on Feldenkrais in Movement Therapy for Children with Cerebral Palsy and Other Neurological Impairments.71

Rolfing Structural Integration
Rolfing is a series of manual manipulations of the soft tissue, or neuro-myofascial system of the body focused on improving the alignment and the level of freedom or spaciousness in the body. The Rolfing community refers to structural fixations in a body as lesions, which is addressed in this physical manipulation phase of the Rolfing process. One could envision the structural manipulation to be a cross between deep tissue massage and chiropractic work, where one tries to lengthen, hydrate, and relax muscles while aligning the body and redistributing the body ‘load’ in a more optimal way. The practitioner uses long, slow strokes using fingers, fists, or elbows in an attempt to free and release fascial holdings. The Rolf movement, similar to physical therapy, works to educate individuals of movement patterns and preferences, while giving the client additional options to explore. It is the Rolfer’s goal to weave both the structural/lesion and movement/inhibition work into an individualized process that encourages integration, motility, and coherence of the body.
Spinal manipulation involves a range of manual (hands-on) manoeuvres that stretch, mobilize or manipulate the spine, surrounding tissues and other joints in order to relieve spinal pain and improve mobility.5
A study done by John t. cottingham et al, on effects of a soft tissue mobilization procedure, the Rolfing pelvic lift, on parasympathetic tone was studied in healthy adult men. The results of this study contribute to understanding of pelvic mobilization techniques and may help to explain why these techniques have been clinically successful in treating myofascial pain syndromes and other musculoskeletal dysfunctions characterized by reduced parasympathetic tone and excessive sympathetic activity.72
A study done by MT Cibulka, et al, showed the Treatment of the Sacroiliac Joint Component to Low Back Pain.27
A study done by John t. cottingham et al, showed the effects of soft tissue manipulation (Rolfing method) were evaluated on young healthy men using two dependent variables: 1) angle of pelvic inclination and 2) parasympathetic activity.28
 
METHODOLOGY
Source of Data:
Data was collected from physiotherapy OPD of Doon Paramedical College & Hospital, Dehradun and, MDM hospital Jodhpur during the study period of December 2010 to May 2011.
Method of Data Collection:
The method of data collection used for this study was a primary method.
Study Design:
The study design used for this research was randomized comparative study.
Sample size:
The sample size used for this research study was 40. Sample selected was heterogeneous.
Study sample:
The study sample consisted of both male and female participants referred to the physiotherapy outpatient department with diagnosis of Chronic Low back pain.
Sampling design
Sampling design used for this research was random sampling (Envelope method) with allocation to 2 study groups.


Participants
There were 40 participants with Provisional diagnosis of Chronic LBP.
Inclusion Criteria:
1. Both male and female participants who reported experiencing Chronic LBP.
2. Provisionally diagnosed by therapist.
3. Age group between 35-45 years.
4. All subjects with symptoms for a duration of more than 3 months..
5. Participants willing to participate in the study.
Exclusion Criteria:
1. Experienced low back pain for less than 3 month of duration.
2. Sought professional treatment during the study.
3. Had acute injury or active neurological symptoms.
4. Patient who were heavily medicated
5. Subjects unwilling to participate in the study
Materials (Figure 3.1)
• Data collection sheet, Consent form & Assessment Sheets
• Measuring Tape
• Towel
• Weighing machine
• Miscellaneous – Couch (Plinth of size 6.5 feet length; 2 feet breath & 2.5 feet height.) & Chair.

3.1-: Instruments used









 
Variables:
1. Independent variable:
 Feldenkrais Method
 Rolf’s soft tissue Mobilization
 Back exercises
2. Dependent variable:
 Visual analog scale
 Modified Oswestry Low back pain disability questionnaire
Apparatus and Equipments
1. Measuring Tape: (Figure3.1)
A measuring tape of total length of 60 inches/152 centimeters was used to measure the height of each patient. The participant was made to stand against a wall, head and heel touching the wall and a mark was made on wall at the vertex of head. The distance between the floor and the mark was measured in centimeters and considered as of the participant.
2. Weighing machine: (Figure3.1)
A standard weighing machine with 1kg increment was used to measure the weight of each participant in kilograms.



Main Outcome Measures
Pain intensity:
By Visual analogue scale – A scale of 10 cm to evaluate intensity of pain where 0 represents no pain and 10 represent unbearable pain.
Physical Function outcome:
The Modified Oswestry Low back pain disability questionnaire includes 10 items with score ranging from 0-50; where better function is indicated by lower scores.
Procedure
Participants who reported to Doon Paramedical college & hospital, Dehradun, and MDM hospital Jodhpur, with Chronic low back pain with duration not less than 3 months were screened for their eligibility depending on inclusion and exclusion criteria to participate in this study. After finding their suitability, they were requested to participate in the study. Then the informed consent was obtained. Following this, a standardized history which consisted of demographic information including age, gender, body weight, height, nature of symptoms and occupation was collected. Weight (in kilograms) of the participants was recorded using a simple bathroom weighing machine. Height (in centimeters) of the participants was recorded using a measuring tape. Duration of the symptoms and initial evaluation of the pain profile was done using Visual Analogue Scale (VAS) and Modified Oswestry Low back pain disability questionnaire (MOLBPDQ) scoring was done. The pain was recorded by 10 cm horizontal visual analogue scale (VAS), the participants were asked to mark their intensity of pain on a 10 cm long line in the data collection sheet with numbers 0 to 10 where 0 symbolized no pain and 10 was severe pain. The Modified Oswestry Low back pain disability questionnaire includes 10 items with score ranging from 0-50; where better function is indicated by lower scores. This questionnaire has been designed to give information as to how patient back pain has affected his ability to manage in everyday life.
Thus the data collected was taken for further analysis.
After this initial evaluation, they were randomly allocated to one of the two study groups A and B.
Group A participants were treated with feldenkrais therapy for 20 minutes and back exercises. Group B participants were treated with Rolf’s mobilization for 90 seconds with 3 repetitions and back exercises.
Group A: Participants were treated with
1. Feldenkrais therapy by gently guides the patient, physically, through the patterns of movement involves subtle touch and direction. During the lesson the patient is able to feel their own relative patterns of holding, to discover which areas of the body are included in their image.
Each lesson had a specific learning theme:
Class 1: “Activating flexors” (supine exercises, flexion as a main theme), (Fig. 3.4-A)
Class 2: “Activating flexors” (adding larger and faster movements, such as rolling supine to sitting), (Fig. 3.4-B)
Class 3: “The pelvic clock” (supine differentiated movements of the pelvis, involving rolling and twisting), (Fig. 3.4-C)
Class 4: “Side lying lesson for improving the integration of arms, shoulders and spine” (reaching motion of shoulders in different directions), (Fig. 3.4-E)
Classes 5 & 6: “Transitioning from supine to side lying to sitting” (lying supine involving flexion, extension, and twisting), (Fig. 3.4-F)
Class 7: “Twisting on the side” (lying on each side to differentiate the movements of the rib cage from the movement of the shoulder blades), (Fig. 3.4-G)
Class 8: “Twisting from supine with head fixed to the side” (by limiting the movement of the head, the rib cage is forced to participate in the twisting motion), (Fig. 3.4-D)

2. Exercises for –
 Increase stability of the spine by strengthening of weakened muscles-
1. Pelvic Tilting
Starting position - crook lying on a firm surface. Exercise - the abdominals and the glutei are tightened and the patient "presses" his lower back down flat. Holding his back flat to the surface, the buttocks are elevated. This permits smooth pelvic tilting and gives the patient the kinesthetic concept of this tilting movement and at the same time stretches the lower back. (Fig. 3.3-A)


2. "Sit Up" From Supine Position with Hips and Knees Flexed
Starting position - Crook lying on a firm surface. Exercise - Head and shoulder are lifted with a gradual curl to touch the knees with the hands. (Fig. 3.3-B)

 Increase mobility of the spine by streching of tightened soft tissue
1. Low Back Stretching Exercise
Starting position - supine lying. Exercise - flex one hip and knee to touch the chest with rhythmically passive bouncing at end range. This is repeated for the other leg with emphasis on the lower back being stretched. (Fig. 3.3-C)
2. Hamstring Stretching Exercise
Starting position - sitting with hip and knee of one leg fully flexed and rotated outward, and the leg being stretched extended on the floor with the knee straight. Exercise - patient tries to reach towards the toes of his extended leg in a bouncing rhythmical manner. The flexed leg prevents stretching of the low back. (Fig.3.3-D)
Group B: Participants were treated with
1. Following the Back exercises as mentioned in group A participants were then treated with the Rolf’s mobilization.
2. Rolf’s mobilization where placing the patient supine with the spine laterally flexed to the left. Therapist stood on the right side of the patient. The patient’s hands were clasped behind his neck. Therapist threaded one arm through the patient’ clasped hands, rotating the upper trunk toward therapist. Therapist then placed own free hand on the patient's ASIS that was furthest away from therapist. Therapist applied a posterior force to the ASIS while the patient maintained full upper trunk rotation. This position is held for 90 sec with 3 repetitions i.e. total of 270 seconds was given.






3.2-: Rolf mobilization


All the subjects were advised:
 To use soft heel foot wear,
 Not to stand for long time,
 Not to walk bare foot,
 Participants were instructed not to do any stretching exercises at home.
All the participants received the selected treatment 8 sessions over a period of 4 weeks.
VAS score and Modified Oswestry Low back pain disability questionnaire (MOLBPDQ) were measured pre and post intervention.
After 4 weeks of intervention, post treatment outcome measures were recorded and data thus obtained was used for statistical analysis.

















3.3-A: Pelvic tilting


3.3-B: “Sit up”



3.3-C: Low back Stretching exercises





3.3-D: Hamstring stretching exercises






3.4-A: Activating flexor




3.4-B: Activating flexor


3.4-C: Pelvic clock



3.4-D: Class 8

3.4-E: Side lying lesson



3.4-F: Side lying lesson


3.4-G: Twisting on the side






PROTOCOL
Subjects meeting the inclusion criteria

Subjects included in the study (n=40)

Informed consent form & approval from ethical committe

Assessment was done & Filled by molbpdq

Subjects randomly assigned into two group




Group A (n=20)
Mean Age ±S.D
37.33±10.80 Group A (n=20)
Mean Age ±S.D
37.33±10.80

Feldenkrais therapy,
Back exercises. Rolf’s mobilization,
Back exercises.

1st & 8th Session 1st & 8th Session



Data collection


Analysis
 
OBSEVATION AND DATA ANALYSIS

Statistics are performed by using SPSS 13 and SIGMASTATE .Results are calculated using 0.05 level of significance.
Level of Significance → 95%
P < 0.05 → Significant
P > 0.05 → Not Significant
FORMULAE USED-

Paired t- test:
∑d2 _ (∑d)2 = s (in paired data)
n-1 n(n-1)


s.d. = s = ( x- x )2
n
∑d
d = n
tcal = | d | , d = x- y = difference in paired values
S. E.
S.E. = s / √ n
d.f. = n - 1
Where d = x- y = difference in pair values
n = no. of subjects,

Arithmatic Mean

∑x
x = n


∑y
y = n

Coefficient of correlation:



Σ(x-x). (y-y)
r =
Σ(x- x)2 Σ(y-y)2

t- test of independent mean:

Where




is an estimator of the common standard deviation of the two samples: it is defined in this way so that its square is an unbiased estimato of the common variance whether or not the population means are the same. In these formulae, n = number of participants, 1 = group one, 2 = group two. n − 1 is the number of degrees of freedom for either group, and the total sample size minus two (that is, n1 + n2 − 2) is the total number of degrees of freedom, which is used in significance testing.
Test of significance of correlation coefficient:



r

t = (1 – r2) / (n - 2)

Where r = correlation coefficient
n= no. of subjects
d.f. = n-2
GROUPS DESCRIPTION
Total Subjects à 40
Group A à 20 (FELDENKRAIS THERAPY)
Group B à 20 (ROLF’S MOBILIZATION)
Level of Significance à 95%
P < 0.05 à Significant
P > 0.05 à Not Significant
RESULTS
The present study was done to compare the effect of Feldenkrais therapy and Rolf’s mobilization in Chronic low back pain. The study included 40 participants, out of which 20 individuals participated in Group A who were treated by Feldenkrais therapy, Back exercises. While remaining 20 subjects participated in Group B who were treated by Rolf’s mobilization, Back exercises. A student t – test was used to compare the Performance of Group A and Group B for different treatments and to find their effectiveness’ within the groups we applied paired t – test. The t – values for Pre – VAS, Post- VAS, Pre –MOLBPDQ and Post- MOLBPDQ are 10.66, 10.3, 11.46 and 12.7 for Group A and Group B .
The results of the study suggest that t value is highly significant in each Pair of both Group A and Group B.Which reveals that the treatment given to both the Groups, Feldenkrais therapy and Rolf’s mobilization are effective. The mean ± s.d. values for Pre- VAS, Post- VAS, Pre- MOLBPDQ and Post- MOLBPDQ for Group A are 6.7±1.68, 1.9±2.1, 45.22±12.9 and 12.27±11.48 respectively. The mean ± s.d values for the same exercises for Group B are 7.3±1.41, 2.65± 2.2, 50.01± 10.32 and 17.14± 10.23 respectively. This result shows that the treatment given to the Patients in Group A is more effective than that of Group B. i.e. The Feldenkrais therapy is more effective than Rolf’s mobilization.




STATISTICAL ANALYSIS:
Statistical analysis for the present study was done manually as well as using the statistics software SPSS 13 and SIGMASTATE so as to verify the results obtained. For this purpose data was entered into an excel spread sheet, tabulated and subjected to statistical analysis. Various statistical measures such as mean, standard deviation and tests of significance such as paired‘t’ test were utilized for this purpose for all the available scores in all the participants. Nominal data from patient’s demographic data i.e. age, sex distribution were analyzed using‘t’ test. Intra group comparison of the pre interventional and post interventional outcome measures was done by using student paired‘t’ test . Probability values less than 0.05 were considered statistically significant and probability values less than 0.0001 were considered highly significant.
Statistical measures such as unpaired' test were used to analyze the data. The results were considered to be statistically significant with p<0.05.
Paired’t’ test was used to compare the significance of difference in pre & post treatment scores within the group.
Unpaired’t’ test was used to compare the significance of difference in pre - pre & post - post treatment scores between the group.
DEMOGRAPHIC PROFILE:
Sex distribution:
The gender ratio of Group A was 14:06 (14 males and 6 females) and Group B was 11:09 (11 males and 9 females) and this was not statistically significant (p=0.432). Therefore both the groups are matched with respect to age and gender. (Table No.5.1I)
Age distribution:
Age of the participants in this study was between 35 to 45 years. The mean age of the participants in group A was 38.45 years ± 3.54 and the mean age of participants in group B was 39.15 years ± 3.95. The difference in mean age of two groups was not statistically significant (p= 0.211). (Table No. 5.1)
Anthropometric measurements:-
Body weight:
The mean Body weight of the participants in Group A was 65.15 kgs ± 8.95 where as the mean weight of the participants in Group B was 64.0 kgs ± 7.61. The difference in mean body weight of two groups was not statistically significant (p= 0.543). (Table No. I5.1)
Height:
The mean height of the participants in Group A was 166.25 cms ± 9.13 where as the mean height of the participants in Group B was 162.85 cms ± 8.10. The difference in mean height of two groups was not statistically significant (p= 0.295). (Table No. 5.1)



Body Mass Index:
The mean BMI of the participants in Group A was 23.72 ± 2.90 where as the mean BMI of the participants in Group B was 24.12 ± 2.20. The difference in mean BMI of two groups was not statistically significant (p= 0.878). (Table No. 5.1)

 Outcome measures considered in this study were Visual Analogue Scale (VAS) score and Modified Oswestry Low back pain disability questionnaire (MOLBPDQ) :
Results were analyzed in terms of reduction in VAS score for pain relief and reduction in MOLBPDQ score for improvement in functional ability.
Visual Analogue Scale Score Analysis (VAS in cms):
In the Group A, the mean VAS score on pre session on the first day was 6.7 cms ± 1.68, which was reduced to a mean of 1.90 cms ± 2.1 on post session i.e. on the 8th session. The p value by paired‘t’ test was found to be < 0.0001 which is statistically significant.
In Group B, the mean VAS score on pre session on first day was 7.3 cms ± 1.41, which was reduced to a mean of 2.65 cms ± 2.25 on the post session i.e. on 8th session. The p value by paired‘t’ test was found to be < 0.0001 which is statistically significant.
On comparing the pre session and post session values, the results between the two groups using unpaired ‘t’ test revealed that there was no statistically significant difference seen with p values of 0.22 and 0.256 respectively.(Table 5.2, Table 5.3) (Graph 1 and 2)
Modified Oswestry Low back pain disability questionnaire (MOLBPDQ in %):
In the Group A, the mean MOLBPDQ on pre session on the first day was 45.22% ± 12.90, which was reduced to a mean of 12.27% ± 11.48 on post session i.e. on the 8th session. The p value by paired‘t’ test was found to be < 0.0001 which is statistically significant.
In Group B, the mean MOLBPDQ on pre session on the first day was 50.01% ± 10.32, which was reduced to a mean of 17.14% ± 10.23 on post session i.e. on the 8th session. The p value by paired‘t’ test was found to be < 0.0001 which is statistically significant.
On comparing the pre session and post session values, the results between the two groups using unpaired ‘t’ test revealed that there was no statistically significant difference seen with p values 0.870 and 0.545.(Table No.V, Table VI) (Fig 3 and 4)










Table 5.1: Mean & SD of Demographic Data for Group A & Group B





Group A
Group B

Mean
SD
Mean
SD

Age(yrs)
38.45
3.54
39.15
3.95

Height(cm)
166.25
9.13
162.85
8.10

Weight (Kg)
65.15
8.95
64.0
7.61

BMI (Kg/m2)
23.72
2.9
24.12
2.2









Table 5.2: Mean and SD of Pre VAS and Post VAS for Group A and Group B

Session
Group A
Group B


Mean

SD

Mean

SD

PRE VAS
6.7
1.68
7.3
1.41

POST VAS
1.90
2.1
2.65
2.25


Table 5.3: Comparison of mean values between Pre VAS and Post VAS within Group A and Group B

Session

Group A

Group B


t value

P value

t value

P value


PRE – VAS
VS
POST – VAS


10.68


P = 0.000

(P<0.05)


10.3
P= 0.000

(P < 0.05)
Table 5.4: Mean and SD of Pre MOLBPDQ (%) and Post MOLBPDQ (%) for Group A and Group B

Session

Group A

Group B


Mean

SD

Mean

SD

Pre FFI
45.22
12.90
50.01
10.32

Post FFI
12.27
11.48
17.14
10.23

Table 5.5: Comparison of mean values between Pre MOLBPDQ and Post FFI within Group A and Group B

Session

Group A

Group B


t value

P value

t value

P value

PRE – FFI
VS
POST – FFI


11.46
P = 0.028

(P<0.05)


12.7
P= 0.000

(P < 0.05)
Table 5.6: Mean and SD of Mean Difference Pre VAS- Post VAS and Pre MOLBPDQ- Post MOLBPDQ for Group A and Group B.






MD

Group A

Group B


Mean

SD

Mean

SD

Pre –Post(VAS)
4.85
2.03
4.6
2.0

Pre- Post(MOLBPDQ%)
32.99
12.82
32.8
11.35














Graph 5.7:





Graph 5.8:






Graph 5.9:





Graph 5.10:






Graph 5.11:





Graph 5.12:






Graph 5.13:





Graph 5.14:





Graph 5.15:






Graph 5.16:


 
DISCUSSION
The present clinical trial was conducted to compare the effectiveness of FALDENKRAIS THERAPY and ROLF’S MOBILIZATION in Chronic Low Back pain with a Back exercises to both the groups.
In the present study Group A received Feldenkrais Therapy and Back exercises and Group B received Rolf’s Mobilization and Back exercises. Both groups had equal number of participants and had shown no significant difference with respect to their gender distribution, which could have altered the results of the study.
The results from the statistical analysis of the present study supported experimental hypothesis which stated that there will be beneficial effect to the participants treated with Feldenkrais Therapy. The mean values of data from present study indicates that the group A treated Feldenkrais Therapy and Back exercises showed better reduction of pain and improvement in functional ability in terms of VAS and MOLBPDQ respectively.
In present study age group of participants was between 35 to 45 years, although the range has been reported to be 10 to 80 years of age.35 A study reported that low back pain is a common orthopedic problem that generally occurs in persons ranging from 20 to 70 years of age.35
Mean Body Mass Index (BMI) of the participants for both the groups were 23.72 ± 2.90 for group A and 24.12 ± 2.20 for group B (Table 5.1). According to WHO standard ideal BMI is in the range of 18.5 - 24.9.74
Analysis of pain relief was done by subjective VAS by statistical mean. Mean and standard deviation of pain in terms of VAS was done and found that the average of VAS score for group A on 1